14055 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• I� BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
ABUILD.ORENG
vOREss BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 14055
OWNER'S PLAN CHECK VALIDATION
NAME- QTY. ELECTRIC PERMIT FEE
\ �Y)eA..NE O
NAMERiCrGRS UTLETS-SWITCHES-RECEP 10.00/1.00 f
LIC.NO, LIGHTING FIXTURES 10.00/1.00
AcroR's
DDRES5 APPLIANCES-RESIDENTIAL 4.00
GDRE5
PHONE PANELS 10.00 DATE OF APPLICATION
ORRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
F o O LICENSED CONTRACTORS DECLARATION
¢U v I hereby affirm that I um licensed under provisions of Chapter 9 _ orris L ISE DATE/
y a m (commencing with Section 7000)of Division 3 of the Business and BLDG:"T ECT. PLG. MECH.
r D z Professions Code,and my license is in full force and effect. V
Z 0 vi W License Class Lic.Number
Date Contractor
Q Y J BUILDING PERMIT
¢ ¢w a OWNER-BUILDER DECLARATION
D
v'x ;LL H I hereby affirm nn that I am exempt from ContractorINFORMATION
's License MISC.- REFER TO ORD
FLL0j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Anycity Onexonty which requires a permit to construct,alter,
d.�
¢ ¢Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. � oC
D ¢ requires the applicant for such permit to file a Signed Statement that TOTAL 9,L3 --
he is licensed pursuant to the provisions of lite Contractor's License PERMIT TO
so
Law(Chapter 9(commencingwith Section 7000)ofDivision 3 ofthe CM�u� L
E4 D Business and Professions Code)or(hat he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3 _ by any applicant for a permit subjects the applicant loa civil penalty gLTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.urvlTs
• their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
L � property who builds or improves(meson and who docs such work FIXTURES-PER TRAP 5.00 SO.FT FLOOR AREA TOTAL ACREAGE
himself re through tinto his own employees,provided that such improve-
mimprovnmintendedorocl'e onefor sale,
Year
If,mpletion the the ower GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have lite burden of proving that he did not build or im- BUILDING USE
Prove for purpose ocsale.). INDUSTRIAL WASTE INTER. 3000 RES IND CON PB oma,
❑ 1,as owner of the property,am exclusively contracting with . 1:1 El El El El
licensed cmRacmn to mi,ruct the project(Sec 7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSOR$PARCEL NO.
and Professions Code:the Contractor's License Law does not apply .
to an owner of Property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts('or such projects with u eantructoRs)licensed pursuant to
the Contractor's lcense Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCELNO.
❑ lam cxe tender Sea ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner )ate WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORKER COMPS SATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See,3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished.
z Z ❑ Certified copy is filed with the city inspection division. FIRE SPRINK ENERGY T 24
F O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y E] N[]
CC CER'1'I17ICATI:01:EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.CONTR. ❑C.NO. PLG.
(This Section need nm he completed if the permit is for one TOTAL Y 0 No Y 0 No
Z hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
O Qbecome subject to the Workers'Compensation Laws of California.
Datc APPlica"t
y ALTER OR ADD TO MECH. 5.00 BUILDING 0 ��
} of NOTICI7 1'0 APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 500 PLAN CHECK /
provisions of the Labor Code, you must forthwith comply with . (�
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec.
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
_ Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC a0 0'l7`
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00
hereby entiorid representatives forms of this city es enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned Property forinsp of
this
purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any y accrue- gains[ Said City in consegu nee f the PERMIT ISSUANCE 10.00
m
gnting0 rspermil' MECH.CONT. LIC.NO. MECH.
O 6 TOTAL TOTAL 3 7
Sin p r of scant/ ant actor ate
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING PERMIT NUMBER
CITY OF CUPERTINO 14055
,• INSPECTION DIVISION
JOB INSPECTION RECORD
, PERMIT EXPIRATION
JOB ADDRESS 874 E. ESTATES UNIT# LOT#
PERMIT EXPIRES IF WORK
OWNER GREGORY JONES CONTRACTOR IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
FOUNDATION
UFER LASTCALLED INSPECTION.
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING +'I/ C
ELECTRICAL � �'� ISSUANCE DATE
MECHANICAL L -BLDG. ELECT, OPLL. MECH.
( u\® ` ❑ '❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED "' BUILDING PERMIT
WOOD FLOOR INFORMATION
PLUMBING VALUATION $/FT,
MECHANICAL
ELECTRICAL PERMIT TO
FRAMING
INSULATION STORIES TYPE CONSTR
• OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
r� ROOF SO.FT FLOOR AREA TOTAL ACREAGE
DIAPHRAGM BUILDING USE
_ RES IND CON PB 00",
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED L El El ❑ [I
ROUGH ASSESSORS PARCEL NO.
PLUMBING
GAS TEST TRACT NO. PARCEL No.
MECHANICAL
ELECTRICAL 10 `d $7 FINALS DATE INSP. ACC,DATE ACC FRE NO.
FRAMING Ip ? SAN #
INSULATION PLUMBING ZONING ENG SITE NO.
GAS
MECHANICAL FIRE SPRINK ENERGY L]E
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING YE] NEI Y ❑ NE
LATH—INTERIOR ELECTRICAL FLOOD ZONE A.L.u.c.
-/G-
LATH—EXTERIOR FIRE DEPT. Y❑ N❑ YO N❑
SHEETROCK GRADE
FEE SUMMARY
SHEAR INTERIOR BUILDING h —//a �'�
SHEAR EXTERIOR TEMPO ARY APPROVALBy BUILDING
FIREWALLS ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING ISNOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
• ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
o� ONE WORKING DAY BEFORE REQUIRED INSPECTION.
z
PLEASE GIVE JOB ADDRESS WHEN PHONING. PLUMBING
- SEE PERMIT FOR EXPIRATION DATE - MECHANICAL
IMPORTANT! CONST.TAX_
PLEASEREAD REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION. =
OFFICE COPY 1